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Annuities are really confusing. But in today’s medical world, you may hear that annuities can be “Medicaid friendly.” What exactly is a “Medicaid friendly annuity”? Simply stated, they are funds converted into an annuity that Medicaid treats as an exempt resource and only as income which allows for (sometimes) immediate Medicaid approval for nursing home, assisted living and home based care. Under New Jersey law, a traditional commercial annuity does nothing to protect assets from the cost of long term care. In fact, without careful planning, simply investing in an annuity will result in the unnecessary loss of assets and a denial of Medicaid benefits. Understanding why this is requires some understanding of estate planning, elder law, and annuities. By taking the time to understand annuities you can easily save tens if not hundreds of thousands of dollars. Planning for disability will greatly increase the likelihood of having something to pass on to heirs, while at the same time reducing stress and maximizing one’ own independence.

What is a Commercial Annuity?

Annuities can be either assets or income streams. Alone that doesn’t mean much. Stay with me. When initially purchased, most annuities are like certificates of deposit with a longer term and a greater penalty for early withdrawal. Such annuities are assets and are said to be “deferred “or immediate. An immediate annuity means money can be taken out right away. Deferred annuities do not pay out interest right away.

I continue our discussion on annuities in a future post(s).

Contact me personally today to discuss your New Jersey Medicaid matter. I am easy to talk to, very approachable and can offer you practical, legal ways to handle your concerns. You can reach me toll free at (855) 376-5291 or e-mail me at fniemann@hnlawfirm.com.

I read an interesting case, which frankly brought up an issue I had not contemplated which is; must a medical service provider (i.e., a doctor, hospital x-Ray technician) bill a Medicare/Medicaid patient directly for services etc. rendered rather than Medicare or Medicaid directly? I pretty much assumed that if you are eligible for Medicare or Medicaid and receiving services, there would be no reason for a nursing home or other medical provider to bill anyone but Medicare/Medicaid, otherwise, the provider would go unpaid. Apparently, in this case, the patient was a plaintiff in a fairly substantial personal injury lawsuit and the hospital billed the patient directly rather than Medicaid to which he had become eligible after the lawsuit was filed which brings us to the origin of the conflict. The article is interesting because it lays out the circumstances under which medical providers can and cannot privately bill individuals for medically related services rather than Medicare/Medicaid. I have given you excerpts of the opinion for your review.

Here’s The Law

Federal Medicaid law precludes direct patient billing in specific instances. Section 1396a(a)(25)(c) of the law prohibits medical providers from “substitute billing” and “balance billing”. A medical provider engages in substitute billing when it already has accepted payment from Medicaid but tries to refund the payment in order to bill the patient directly, usually because Medicaid reimbursements are often much lower than the provider’s “customary fee[s],”. “Balance billing occurs when a provider accepts payment from Medicaid and then seeks to recover from the patient the balance between that payment and the customary fee.” Thus, § 1396 a(a)(25)(C) becomes relevant once the provider has billed Medicaid and accepted payment for services proved to be beneficiary. The law does not bar a provider from taking a chance that a Medicaid-eligible patient has a non-Medicaid source of payment for the medical services rendered. The provider may opt to attempt collection directly from the patient or a liable third party instead of seeking a certain but likely reduced payment from Medicaid.

To discuss your NJ Elder Law Medicare and/or Medicaid matter, please contact Fredrick P. Niemann, Esq. toll-free at (855) 376-5291 or email him at fniemann@hnlawfirm.com. Please ask us about our video conferencing consultations if you are unable to come to our office.

The Medicaid application process differs state to state. In New Jersey, the county Medicaid office is generally available to answer questions about, qualifying for Medicaid, as well as the ins and outs of the application process. But good luck getting a live person or a call back, especially in Essex, Camden and Mercer counties.

You have one option when completing a Medicaid application:

You can mail in your application. Mail ins have recently been approved in virtually all counties.

Complete an application in person at the county Medicaid office in Freehold, Toms River, Trenton, New Brunswick, Elizabeth, etc.. Check the address of your county Medicaid office.

A phone application is never permitted!

Information to Have on Hand for Your Medicaid Application

When completing your Medicaid application, you will need the following:

Birth certificate or driver’s license

Social security card or proof of alien status.

Paystubs, Social Security statements, Supplemental Security Income, Veteran’s Benefits, or other retirement income or tax return to prove your income.

Proof of any financial assets available to you.

Proof of disability – If you are completing a Medicaid application because you’re disabled, your doctor may need to submit documentation as specified on your Medicaid application.

Proof of residence.

Your red, white and blue Medicare card or other proof of insurance.

Contact me personally today to discuss your New Jersey Medicaid application. I am easy to talk to, very approachable and can offer you practical, legal ways to handle your concerns. You can reach me toll free at (855) 376-5291 or e-mail me at fniemann@hnlawfirm.com.

Local social services agencies continue to prepare for the registration of new Medicaid-eligible residents in the New Year.

It could mean adding new staff to handle the influx as well as a reduction in state funding expected to be covered with the new federal dollars, officials said.

Effective Jan. 1, an estimated 1,900 Culpeper County residents could become eligible for health coverage through Medicaid per the Affordable Care Act expansion approved earlier this year by the Virginia General Assembly.

Rappahannock Rapidan Community Services Board Director Jim LeGraffe gave a presentation on the topic last week at the Culpeper County Board of Supervisors meeting. The agency provides services as well in the surrounding counties, where residents will also be newly eligible to get Medicaid – 1,600 in Fauquier, 700 in Madison, 1,200 in Orange and 300 in Rappahannock, according to LeGraffe.

Supervisor Sue Hansohn asked how his agency was gearing up to handle the new caseloads.

“How many more employees will you need and will the state pay for that?” she asked.

LeGraffe responded by saying community services board statewide would experience a reduction in state allocations to cover the estimated $200 million cost to Virginia to expand the program. He noted his agency “accepts patients regardless of their inability to pay.”

Providing expanded Medicaid access to these same patients will “fill up that void,” LeGraffe said, of the federal government’s pledge to pay at least 90 percent of the expansion cost.

“That is the big hope,” he said, adding, “Hope is not a strategy.”

LeGraffe said his agency would work closely with Culpeper County Department of Social Services to get newly eligible residents enrolled in the health coverage program as quickly as possible “so we are able to maintain a funding stream.” The Medicaid expansion will allow the local community services boards to bill the federal program for the additional patients not previously covered.

Hansohn reiterated her worry that staff would be inadequate to handle the new caseload.

“With the same number of people serving additional folks, it’s going to be rough,” she said.

LeGraffe said his agency would continue to recruit for any needed positions.

Of Rappahannock Rapidan Community Services Fiscal 2019 budget of $26.4 million, 36 percent or $9.5 million comes from Medicaid fees paid on behalf of clients already covered by the program, he said.

Per Virginia’s plan to expand Medicaid, hospitals will be taxed to generate revenue for the state’s 10 percent share of the roughly $2 billion annual cost. Under the Affordable Care Act, newly eligible for Medicaid are people with incomes up to 138 percent of the federal poverty level—$16,750 a year for an individual and $28,700 for a family of three.

Culpeper Human Services Director Lisa Peacock said her agency is preparing for its role in the Medicaid expansion.

“We will be ready when enrollment begins,” she said.

Eligibility Supervisor Teresa Jenkins said enrollment would be done at different levels beginning Jan. 1. People already enrolled in mental health coverage through the Governor’s Access Plan who meet the new income guidelines will automatically be enrolled for Medicaid directly at the state level, she said.

Additional enrollments will take place at the central processing unit in Richmond based on identified targeted groups, Jenkins said, while other applications will be processed through the Marketplace when someone applies for their services.

Other populations will be part of a mass mailing in October to food stamp recipients not on Medicaid and will be able to respond to the local agency or state central processing unit to sign up, she said.

In addition, starting in November citizens may make application online, at the call center or at the local agency and those applications will be processed by the local DSS office, according to Jenkins.

It will likely result in new employees needing to be hired.

“We are gearing up for the additional potential Medicaid recipients in our local office and the man power to be able to process the applications,” Jenkins said. “DSS is currently advertising to hire additional staff that will needed and educating the community on what the new guidelines are. We have received some phone calls on the new category and I am sure that will increase closer to the release date of the program.”

Madison County DSS is currently advertising online to hire a benefit program specialist I with a job title to include the processing of Medicaid applications “within strict timeframes.” The annual salary advertised for the position is $27,366.

T-R PHOTO BY MIKE DONAHEY
Democratic candidate for governor Fred Hubbell, left, listens as Mid-Iowa Community Action Health Services Director Gloria Symons makes a point about Medicaid reimbursement at a meeting Friday in the public library’s conference room.

Democratic candidate for governor Fred Hubbell got an earful from one local provider who serves a large number of Medicaid patients.

Substance Abuse Treatment Unit of Central Iowa Executive Director Vicki Lewis called the state’s Medicaid program, run by two managed care companies, “a disaster.” Hubbell met with representatives from SATUCI, Mid-Iowa Community Action and Center Associates Friday at the Marshalltown Public Library.

He asked them to tell of their experiences in dealing with the two managed care companies hired by the state to run the state-funded Medicaid program.

Because of the kind of clients served and agency services provided, the three had equally different levels of experience.

One common denominator is that they are not-for-profit, and rely on prompt and accurate reimbursements from the managed care companies.

Privatization

Medicaid privatization as it is now known was established in 2015 by former Gov. Terry Branstad. Branstad eliminated Iowa’s state-run Medicaid organization and replaced it with oversight from three private managed-care companies.

He and many Republican legislators claimed they would be more cost-efficient in running Medicaid, theoretically saving tax dollars. Initial estimates were savings of $100 million with no reduction in Medicaid services. The $100 million was later revised to $50 million.

The three MCOs were Amerigroup Iowa Inc., AmeriHealth Caritas Iowa Inc. and United Healthcare Plan of the River Valley Inc. AmeriHealth departed, leaving Amerigroup and United Health Care.

Providers’ perspective

“In my experience this entire Medicaid adventure has been a disaster,” Lewis said. “We are not new to managed care, we were under Magellan for 20 years. But now we are living with two (care providers) and unpredictable situations. We never know what is going to be paid and what will not be paid … we are having the most problems with United Health Care.”

Lewis said SATUCI found it necessary to hire an additional employee to manage billing because the MCO system remains complex. In previous meetings, Lewis said SATUCI derives significant amount of overall agency income from Medicaid reimbursement. SATUCI provides substance abuse disorder treatment outpatient and education in Hardin, Marshall, Poweshiek and Tama counties.

Rates substance abuse agencies may charge for care were set 20 years ago by Magellan, which significantly compounds the problem, Lewis said.

“The rates are disastrous to begin with,” she said. “We are paid 30 percent less than those who work in mental health settings get paid.”

Lewis predicted that some agencies will be forced to close. Hubbell said some have.

Health Services Director Gloria Symons said MICA manages a dental care program for low-income residents in Story County. She said cuts and changes in reimbursement levels to the program has made it a challenge “keeping the doors open.”

“We are having to raise other funds to serve clients,” she said. “We are serving some who have had no dental care. Some are in their 40s or 50s, and they have had no dental care for years.”

Symons said at one time MICA was being reimbursed $700 for an individual’s care. The MCOs have since reduced that to $400 or $300 per person. Symons said approximately 2,000 persons were served by MICA annually.

Raise for MCOs

The managed care companies have been in the news recently, as state officials recently authorized a 7.5 percent raise to Amerigroup and United Health Care.

The agreement will keep United Health Care and Amerigroup in Iowa, but it will mean state leaders must come up with

about $103 million more than last fiscal year, according to the Des Moines Register. The new agreements cover the current fiscal year, which began July 1. The increase in state spending is more than double the 3.3 percent increase the state agreed to for last fiscal year.

Overall, the new contracts will give the two companies raises of 8.4 percent in state and federal money, totaling $344 million.

The companies have complained about losing hundreds of millions of dollars in Iowa due to reimbursement rates they said were set far below their costs when the shift to private management began in 2016. AmeriHealth Caritas, bailed out of the project last fall after failing to get the contract terms it sought from Iowa officials.

Hubbell said Iowans are becoming dissatisfied with Medicaid management by the two MCOs.

“Approximately 650,000 Iowans are on Medicaid,” Hubbell said. “They have relatives, friends and others who are experiencing these issues … we have 40,000 Iowans who have had benefits reduced … 14 mental health providers who have been driven out of business. The access to health care is clearly declining in our state.”

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Contact Mike Donahey at 641-753-6611 or mdonahey@timesrepublican.com

DES MOINES — Enrollment is down at three of Iowa’s public universities, but officials said the decline is …

Thousands lose Medicaid coverage in Arkansas after failing to meet work requirements

LITTLE ROCK, Ark. — As many as 4,600 Medicaid recipients in Arkansas have lost their benefits for the rest of this year after failing to meet the state’s new work requirements.

Arkansas became the first state ever to implement work requirements, after gaining approval from the Trump administration earlier this year. Under the new rules, which took effect in June, recipients must work, go to school, volunteer or search for jobs for at least 80 hours a month or be stripped of their coverage until the following year.

The affected beneficiaries, mainly non-disabled adults in their 30s and 40s who don’t have dependent children, failed to report any work activity for three months. This prompted the state to drop them from the rolls. A final tally will be available next week.

State officials said they made many efforts to contact those subject to the new requirement, including sending letters and emails, making phone calls and videos, working with community organizations and setting up a call center to answer questions. Those who could not find employment were offered training. Recipients had to log their hours online, but could designate certain others — such as their Medicaid insurer or a local nonprofit — to do it for them if they did not have access to a computer.

Consumer advocates, however, pointed to the results as proof that work requirements do not help people find jobs. They just add more hurdles for people to get government assistance.

“So far, Arkansas Works doesn’t seem to be incentivizing work at all,” Joan Alker and Maggie Clark, at the Center for Children and Families at Georgetown University, wrote in a recent blog post. “However, what does seem clear is that the new approach (and others like it) will likely result in significant coverage losses for adults who rely on Medicaid coverage for their survival.”

Governor Asa Hutchinson said that some who did not comply may have found work, gained coverage elsewhere or moved out of state without notifying officials.

“Personal responsibility is important,” said Hutchinson, a Republican. “We will continue to do everything we can to ensure those who qualify for the program keep their coverage, but we will also make sure those who no longer qualify are removed.”

Roughly 46,000 Medicaid enrollees were originally estimated to be subject to the work requirements in July, according to the latest state data. (Those ages 19 to 29 will become subject to the new rules next year.)

More than 30,000 of these recipients were already meeting the mandate by working or engaging in other activities so they were exempted from reporting each month. Several thousand more received other exemptions or had their cases closed for unrelated reasons.

Only 844 met the reporting requirement. Of these folks, 145 said they were working and 127 reported they were in school, volunteering or searching for jobs. The rest reported that they were meeting the work requirements for food stamps, which also satisfies the new Medicaid mandate.

These figures show that the new rules prompted only a sliver of enrollees to find jobs or other activities, Alker said in an interview.

Many recipients likely don’t know about the mandate, experts said. Jessica Greene, a professor at Baruch College, found that 12 of the 18 people she interviewed last month had not heard anything about it.

“What I found was a profound lack of awareness about the policy,” wrote Greene in a Health Affairs post, who said a much broader educational effort is needed.

Three consumer groups are suing the Trump administration in an effort to halt the Arkansas program. The National Health Law Program, along with Legal Aid of Arkansas and the Southern Poverty Law Center, filed the lawsuit in US District Court in Washington D.C. in mid-August. It charges that approval of Arkansas’ waiver runs counter to Medicaid’s objective of providing the poor with access to health care.

Consumer activists successfully stopped the implementation of work requirements in Kentucky in June. The Trump administration has also approved requests to implement work requirements in Indiana and New Hampshire, though the new rules have yet to take effect in those states.

WEST MEMPHIS, Ark. — Work, or lose your health insurance — that’s an ultimatum given to Arkansans on Medicaid this summer.

More than 4,000 people have already been dropped from the program after a new 80-hour per month work requirement that took effect in June means some are no longer ineligible for free or low-cost health care.

In lieu of paid work, Medicaid recipients can also report volunteering, school work or job hunting.

That’s not unreasonable, some say.

“If people are sitting at home, wanting insurance for nothing, and they can work, they can help society, man, get up,” says one Arkansan.

But Jacqueline Cannon at the Good Neighbor Love Center in West Memphis, which provides groceries to needy residents, points out that many of the people who come through her doors aren’t in a position to do that.

“You have some people that can’t work, and they still don’t have Medicaid, you know. Some are not receiving any type of assistance no more than Medicaid, and if you cut it out, then they won’t have anything,” she said.

State officials say they made efforts to contact those subject to the new requirements. And, those who could not find employment have been offered training.

Consumer advocates say these results prove that work requirements do not help people find jobs.

Three consumer groups are suing the Trump administration in an effort to halt the Arkansas program

Seems reasonable.The Star Tribune’s Glenn Howatt reports: “Minnesota’s Medicaid program will remove one of the biggest obstacles facing patients who need drug therapy, cutting the red tape that doctors say has impeded their ability to prescribe treatment medications for opioid addiction. … Physicians will no longer need to obtain prior approval from the state agency that runs the health insurance program for the poor, a process that often caused dangerous delays and sent some patients back to using heroin or prescription drugs as a way to cope with intense withdrawal symptoms.”

Should’ve hired a search firm search firm. The Minnesota Daily’s Helen Sabrowsky reports: “Some University of Minnesota Regents say they had no knowledge of an unsuccessful administrative search at the University by the third-party firm hired to find the University’s next president. … The board announced last month that Storbeck/Pimentel & Associates will lead the next presidential search. Regents have voiced concern about the firm’s 2011 search for the position of the University’s Vice President and Chief Information Officer, which some say they were unaware of during the firm selection process. … The candidate hired, Scott Studham, was later asked by President Eric Kaler to resign when allegations of misconduct were discovered from his time of employment at the University of Tennessee. … Regents Michael Hsu, Randy Simonson, Steve Sviggum and Ken Powell said they were unaware of the firm’s involvement in the Studham search.”

Music to Uptown residents’ ears. City Pages’ writes: “Somehow, the forever vacant Suburban World Theatre in Uptown has managed not to become a FootLocker or Ulta or tiny Best Buy. … Now, after five years of languishing, new owners plan to renovate the 1920s-era building and turn it into something Uptown proper doesn’t have at the moment: a live music and entertainment space. … According to Finance & Commerce, the Minneapolis-based Grained Apple LLC, an entity related to developers Doug Hoskin and Amy Reher, has purchased Suburban. The local development group hopes to have it up and running by next spring.”

Teens: never change. The Pioneer Press’ Josh Verges reports: “Farmington High School marching band leaders are making changes to their football halftime show in response to complaints from supporters of President Donald Trump. … The performance of ‘Dystopia’ during last Friday’s game sparked emails and phone calls, Farmington High School Principal Dan Pickens said. … Pickens, who attended Friday’s game, said the show built dramatically to ‘kind of a cool ending’ when the word ‘RESIST’ was spelled out on 10-foot boards. … ‘It was really the word that rubbed people the wrong way,’ Pickens said. ‘Unbeknownst to me, it has a different meaning today.’”

The state began rolling out the rules in June in phases, when 26,000 residents ages 30-49 with no children under 18 at home became subject to the work requirement. Of those, the state exempted about 15,500 based on its own records and another 2,400 claimed exemptions, according to Judy Solomon of the Center for Budget and Policy Priorities, a Washington think tank. That left 8,100 required to report their hours, of whom 4,574, or 56%, failed to comply.